Provider Demographics
NPI:1265450670
Name:THE FOUNDATION FOR HEALTH CARE CONTINUUMS
Entity Type:Organization
Organization Name:THE FOUNDATION FOR HEALTH CARE CONTINUUMS
Other - Org Name:COUNTRY STORE AND PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:KELM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-253-1920
Mailing Address - Street 1:520 1ST ST NE
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-1274
Mailing Address - Country:US
Mailing Address - Phone:320-255-0801
Mailing Address - Fax:
Practice Address - Street 1:520 1ST ST NE
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-1274
Practice Address - Country:US
Practice Address - Phone:320-255-0801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261738-13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN682650400Medicaid
MN682650400Medicaid